GrupoMédicoPOR EL DERECHOA DECIDIRGDC COLOMBIA

Unwanted Pregnancy, Forced Continuation of Pregnancy and Effects

on Mental Health

P O S I T I O N P A P E R

December 2011

Grupo Médico por el Derecho a Decidir - ColombiaGlobal Doctors for Choice (GDC) Network

GrupoMédicoPOR EL DERECHOA DECIDIRGDC COLOMBIA

Grupo Médico por el Derecho a Decidir is a network of doctors

from different specialty areas that advocates for women´s timely,

comprehensive access to sexual and reproductive healthcare

services, grounded in respect for their freedom to make choices.

It is part of the Global Doctors for Choice (GDC) network.

Any part of this publication may be copied, reproduced, distributed or adapted without prior permission from the authors or publishers as long as those who benefit from this material do not copy, reproduce, distribute or adapt it for purposes of commercial gain, and the authors receive credit as the source of said information on all copies, reproductions, distributions and adaptations of the material. Grupo Médico por el Derecho a Decidir requests a copy of any material in which this publication is used.

Design and layout: www.gliphosxp.com

This document was drafted with substantial contributions

from Drs. Efraín Noguera and Laura Gil and the support

of Ana Cristina González V.

GrupoMédicoPOR EL DERECHOA DECIDIRGDC COLOMBIA

Table of Contents

Introduction 5

Summary of the evidence 7

Types of studies and methodological challenges 7Impact of an unwanted pregnancy on women’s mental health 9Impact of forced continuation of pregnancy on women’s mental health 13Our experience in clinical practice as part of the evidence 14Mental health consequences of terminating a pregnancy 14

Some reflections by Grupo Médico por el Derecho a Decidir 16

References 20

5

IntroductionGrupo Médico por el Derecho a Decidir is part of the Global Doctors for Choice network,

which has members in almost every region of the world (Africa, North America, Latin

America and Europe). On the occasion of the network´s launch in Colombia, the group

wishes to voice their position as MD´s belonging to different specialties, regarding the

consequences of unwanted pregnancy on women. Daily experience with this reality

through our medical practice has made us aware of the tragedy suffered by women

who are compelled to face sometimes insurmountable barriers in order to voluntarily

terminate a pregnancy, including, at times, the forced continuation of the pregnancy.

The purpose of Grupo Medico por el Derecho a Decidir is to defend every woman´s

prerogative to take free and informed decisions in the field of sexual and reproductive

health. We emphasize on the importance of finding a legitimate voice that will allow

us to relate our day to day experiences with women seeking sexual and reproductive

health services including legal, voluntary termination or pregnancy (or VTOP), making

it possible to speak up for the protection and respect of women´s decisions and rights.

Stemming from our commitment to promoting women’s healthcare according to the

highest quality standards of care, and based on evidence, we assert that unwanted

pregnancy and its forced continuation affect women’s mental health.

6

There is ample evidence to support the argument that the continuation of an unwanted

pregnancy increases the risk of mental health problems; thus, from this standpoint, any

woman who is forced to carry an unwanted pregnancy to term faces a health risk that

she should not have to face under current legislation in Colombia1 and has the right to

terminate her pregnancy.

1 Ruling C-355/2006. Colombian Constitutional Court.

7

Summary of the evidenceAs doctors, the ethical practice of our profession demands that we ask ourselves

whether the continuation of an unwanted pregnancy involves a health risk to the

patient. In accordance with the principles of evidence-based medicine, the answer must

be comprehensive, based on our experience and expertise and supported by the best

existing evidence in scientific literature.

Types of studies and methodological challengesDespite our observations on a daily basis of the profound and evident effects that

unwanted pregnancy has on women’s mental and social health, it is worth attempting

to demonstrate and measure the existence of this impact from a scientific standpoint,

in an effort to search for an epidemiological response that allows us to:

1. Infer population-level risk.

8

2. Establish more reliable correlations by controlling confounding variables.

3. Establish intensity correlation measurements that may provide useful elements

of judgment at the individual level helping women to make informed decisions

and allowing healthcare professionals to assess the existence of risk; or to

understand the concept of unwanted pregnancy as a health risk. This data is

also a source, at the collective or public level, of useful elements for formulating

public policy in relation to the protection of women’s health.

The search for an answer based on epidemiological data poses interesting methodological

challenges in the area of health research that have been resolved in medical literature

basically through two approaches: The most frequent, because it does not require

prolonged follow-up periods or very select populations, is to try to demonstrate a

statistical correlation between depression or its symptoms and unwanted pregnancy,

during pregnancy and postpartum.

The second approach –which is much more demanding due to the need for prolonged

periods of observation and identification of more specific sub-groups of women–,

is to search for a correlation between long-term effects on mental health and how

an unwanted pregnancy is resolved. In other words, a comparison is made between

women who voluntarily terminate their pregnancy and others who carry it to term due

to factors beyond their control.

These measurements are especially viable in scenarios where due to the legislation,

some women’s requests for abortion are denied because they are not considered to be

exposed to any health risks.

This allows for a comparison of the true effects of the birth of an unwanted child

among a group of women who were forced to continue their pregnancies against their

will.

Based on the previous analysis, we can conclude that, although both types of studies

provide useful evidence, those that assess the impact of the forced continuation of an

unwanted pregnancy provide a much stronger degree of inference. The latter encompass

a subgroup of women that represent the situation of thousands of Colombian women

9

experiencing unwanted pregnancies, whose right to legal abortion is not acknowledged

because their pregnancy is not considered a health risk.

Impact of an unwanted pregnancy on women’s mental healthAn unwanted pregnancy or birth has an effect on the woman, the couple, the child

and the rest of the family. Various studies have specifically shown that women are at a

greater risk for suffering negative health consequences during and after an unwanted

pregnancy.1

Unwanted pregnancy has consistently proven in several studies to be one of the main

risk factors associated with the development of depression during pregnancy2, 3 and

postpartum, 4, 5, 6 and with lower levels of psychological well-being during pregnancy,

postpartum and in the long term.7, 8, 9

In general, as shown in Table 1, women who say their pregnancy is unwanted during

prenatal checkups are, on average, twice as likely to develop symptoms of depression

or anxiety and/or for having higher stress levels.

10

Table 1.Summary of studies that show correlation between unwanted pregnancies and

mental health effects

Author/Year Description of study Findings

Eastwood

2011

Cross-section of 29405 women, Australia

Greater incidence of postpartum depression symptoms among women with an unwanted pregnancy

Bunevicius

2009

Cohort study, 230 women, Lithuania

Greater risk of depression during each trimester of pregnancy among women with an unwanted pregnancy

Lau keung

2007

Cross-section of 2178 women, China

40% greater incidence of high levels of psychological stress and three times greater incidence of high levels of depressive symptoms among those with an unwanted pregnancy.

Rich-Edwards

2006

Cohort study, 1662 women, USA

Twice the risk of postpartum depression among women with an unwanted pregnancy compared to women who wanted pregnancy.

Iramfar

2005

Cohort study, 163 women, Iran

Twice as much postpartum depression among women with an unwanted pregnancy compared to women who wanted pregnancy.

Najman

1991

Cohort study of 6642 women, Australia

Five times greater risk during pregnancy and three times greater risk postpartum of suffering depression among women with an unwanted pregnancy—and who also had a negative reaction toward the pregnancy from the beginning.

Laukaran

1980

Cohort study of 8000 pregnant women, USA

2.6 times greater incidence of psychosocial problems in women with an unwanted pregnancy and negative attitude in regard thereto.

11

In assessing these findings, there may be some question as to whether the mental

health effects are the result of factors which are associated, but not directly related to

pregnancy, such as low socioeconomic status, absence of a partner, low educational

level, drug abuse or the presence of violence, in which case the termination or

continuation of a pregnancy would not factor in as a health risk.

This potential bias is resolved by analyzing each of these variables separately to assess

their impact on mental health. Stratified analyses consistently show that, while some

adverse psychosocial situations can be more frequent among women who experience

an unwanted pregnancy, the sole presence of an unwanted pregnancy correlates

independently with an increased incidence of mental health effects.

A study published by Najman provides the best evidence in terms of proper methodology

and use of a strict definition of unwanted pregnancy. This study carried out a prospective

analysis of 6642 women in Australia starting at prenatal checkups through to 6 months

postpartum. Among the participants, very strict criteria were used to identify women

who did not want their pregnancy, pinpointing 277 who not only had not planned their

pregnancies but also showed an emotionally negative reaction to them during the first

prenatal checkup.

This study only included women who carried their pregnancy to term, so it is possible

that the group might include women who wanted to have an abortion but faced a

variety of barriers, as well as women who grew to accept the pregnancy over time.

It is to be expected that the consequences of an unwanted pregnancy on the mental

health of women who decide to continue with the pregnancy are mitigated to some

extent by acceptance; however, measurements obtained using standardized and

validated psychometric tools in the study of this heterogeneous group of women who

had in general initially rejected their pregnancy showed a clear increase in the risk of

anxiety and depression both during the pregnancy, as well as at one and six months

postpartum.

The risk of depression observed during pregnancy in these women can be up to five

times greater than that of their peers with wanted pregnancies. Even though risk

decreases postpartum, it remains twice as high in comparison to the control group.

The same trend is observed in regards to the risk of developing anxiety.

12

It is important to note that this study did not include women who chose to give their

child up for adoption. It is therefore possible that these correlation measures may have

been even stronger had this subgroup been included, given that they are undeniably,

among those who carried a definitely unwanted pregnancy to term and, therefore, the

most likely to suffer its consequences on their mental health.

Barber9 provides a more long-term look at how an unwanted pregnancy affects the

mental health of women through a 31-year study performed on 1113 women in the

United States. This study showed greater scores of depressive symptoms and lower

indicators of happiness among women who reported giving birth to and raising an

unwanted child in the 1960s, when abortion was illegal.

There are also what may appear to be conflicting results. In a longitudinal study that

followed 1247 women for 13 years after a first unplanned pregnancy, no difference

was found in the incidence of depression between those who chose to terminate

and those who gave birth. This data, however, should be interpreted with caution for

two reasons: The first is that the study group was defined based on the question of

whether the pregnancy was planned, and not on whether it was wanted. The range

of possibilities within this group is very broad since many unplanned pregnancies are

wanted from the beginning. The second reason is that this study was undertaken in

the context of a liberal law within which, in theory, women had the option of choosing

to terminate their pregnancy; therefore, it can be presumed that those who chose to

have an abortion mitigated the effects on their mental health in doing so. It is possible

that, had they not had the choice, a higher degree of depression would be observed in

women who carried their pregnancy to term.

Furthermore, this study showed a higher educational level and long-term income in the

group that opted for an abortion: Two fundamental social determinants in regards to

mental as well as social health.

13

Impact of forced continuation of pregnancy on women’s mental healthThe first studies that attempted to prove the effects of unwanted pregnancy and its

forced continuation on women’s health took place in Europe. These studies were

carried out during periods of transition in abortion legislation when exceptions were

established; therefore, there were instances when abortion requests could be denied.

Despite their lack of rigorous methodology, including shortcomings in the application of

standardized tools for measuring mental health or selecting a proper control group, the

initial approaches to this issue are valuable. They are represented by the classic, long-

term studies of Hook11 and Forssman12 in the 1960s, which followed women whose

abortion requests were denied. In these groups of women, lower rates of mental health

and socioeconomic well-being were observed in comparison to women who were not

facing the same situation.

In a study that applied a more rigorous methodology with appropriate comparison

groups and a sample of 6410 British women, Gilchrist13 found that carrying an

unwanted pregnancy to term , for any reason, is associated with a tendency almost

three times higher than the average of developing self-destructive behavior in the

future; this includes suicidal tendencies. Moreover, when the continuation of the

pregnancy had occurred as a result of the denial of an abortion, this risk increased

twofold in comparison to women who terminated their pregnancy.

In a retrospective study14 in Brazil, where the law is restrictive, the presence of common

mental disorders (depression and anxiety) was assessed among 1121 pregnant women,

finding a very high incidence (63%) among those who wanted to have an abortion or

had tried but failed to have one.

Dagg 15, in a review of the consequences of being denied an abortion, found a variety

of responses to unwanted birth. Invariably, across all studies, there were widespread

negative long-term effects varying from resentment toward the child to symptoms of

mental illness, anxiety and poor psychosocial adaptation.

14

In conclusion, the aforementioned studies showed that the forced continuation of an

unwanted pregnancy increases health risks for women, in addition to the immediate

and long-term effects on mental health, exposing women to depression, anxiety and

unhappiness as a result of the unwanted pregnancy. Therefore, denying abortion,

despite the existing health risks associated, puts women at great risk.16

Our experience in clinical practice as part of the evidenceAn unwanted pregnancy can cause severe anxiety and depressive reactions in a woman

who does not feel emotionally or socially prepared to be a mother. Our daily clinical

practice puts us in direct contact with women going through this situation and provides

us with an up-close perspective of their suffering. The simple notion of carrying an

unwanted pregnancy to term becomes a kind of psychological torture for many women.

Those of us who interview and help them, often witness a painful emotional situation

that is relieved by an abortion.

Mental health consequences of terminating a pregnancyIn 2008 the American Psychological Association published a very thorough report that

provides an analysis of medical literature published in scientific journals since 1989 on

the possible effects of abortion on women´s mental health (APA Task Force on Mental

Health and Abortion).17 The general conclusion drawn from this systematic review is

that terminating an unwanted pregnancy in the first trimester does not pose a greater

mental health risk than the continuation of the pregnancy. They also found that losing

or terminating a wanted pregnancy due to fetal malformation, for example, might

indeed have more consequences on the woman’s mental health.

The determining factor then is not the abortion itself but rather the woman’s wishes

regarding the abortion.

15

An abortion can, in many cases, relieve the stress associated with an unwanted

pregnancy as many studies have shown.17 However, in some instances the decision to

have an abortion is accompanied by social/religious stigma, the woman may be forced

to keep her decision a secret or she may not have a support network to rely on. This

can cause additional stress that is not directly related to the abortion but rather to the

unfavorable circumstances surrounding it.

These authors find that many studies contain evidence of bias against women’s right

to choose. This is manifested in the interventionist fallacy, which poses, with little

methodological clarity that abortion causes increased depression in women and that

therefore reducing the number of abortions will reduce the rate of depression among

women. Those who defend this fallacy have not taken depression rates and rates of

other psychosocial disorders in women who have been denied abortions into account.

Coleman et al.18 recently published a meta-analysis in the British Journal of Psychiatry

in October 2011 in which they found a high rate of mental disorders in women as a

direct consequence of an abortion. However, this study has been highly criticized due

to the vast number of methodological and ethical errors made by its authors, who are

notorious anti-choice activists.

16

Some reflections by Grupo Médico por el Derecho a DecidirThe voluntary termination of pregnancy (VTOP) is a basic, legal procedure when it

involves preventing a risk to the woman’s mental health, particularly in the case of

an unwanted pregnancy. It is therefore closely linked to the healthcare professional’s

duty and commitment to medical ethics and patients’ rights. This statement incites the

following reflections:

On the role of doctors when it comes to women’s decisions

\ In cases when a woman requests the termination of a pregnancy, doctors do

not participate in this decision making. It is not our duty to do so, because it is

not a medical decision. It is an autonomous decision by a woman who sees the

continuation of the pregnancy as something that risks her health and well-being.

\ Safeguarding the possibility of making autonomous decisions is part of

protecting women´s mental health. The greatest health effects on women

17

occur when they are denied access to a legal service and are thus denied

the possibility of making autonomous decisions about their lives and bodies.

Ruling T-009 of 2009 (Colombian Constitutional Court) makes it clear that

no one other than a woman can make the decision to terminate her own

pregnancy, this is encompassed within her right to the free development of

her own personality and must be respected.

\ Legal termination of pregnancy is a health service rendered through a medical

procedure that has indications that are not necessarily medical in nature. For

example, when a woman with an unwanted pregnancy comes to request

a service, she does so in exercise of her constitutional right to the free

development of her personality, i.e., her right to make autonomous decisions.

Doctors are bound to respect the autonomy of all their patients, including

women with unwanted pregnancies who request abortions. .

\ Constitutional Court Ruling C-355 of 2006 does not require doctors to express

their agreement with a woman’s decision to terminate her pregnancy; it only

asks them to acknowledge and certify the existence of a health risk when

there is one. . A doctor may disagree with a woman’s decision, but this cannot

affect his or her ability to acknowledge the risk. In the case of conscientious

objection for moral or religious reasons, the doctor must see to it that his/

her conscientious objection does not become a barrier to access; he/she must

refer the patient to a non-objecting colleague.

\ Denial of abortion services based on dissent with the woman’s decision, is

inappropriate and cannot be understood as conscientious objection, it is

rather an unjustified denial of health services and, therefore, a violation of a

woman’s rights.

\ The certificate that we, as medical professionals, issue to the patient who

requests a VTOP should merely address the existence of a health risk from a

broad perspective (bio-psycho-social), including the life project in its social

and even economic dimensions. On this point, it is worth mentioning that it

would not make sense to a use a narrow definition of health for the purpose

of abortions when we use a broad one for other health issues.

18

On health and an unwanted pregnancy:

\ Maternity is a situation that must be assumed (mentally and emotionally); an

unwanted pregnancy therefore impedes women from taking ownership of

their situation.

\ The existence of a mental health risks and consequently, its certification, does

not require the presence of a mental disorder or illness such as schizophrenia.

Nor does it depend on any set degree of risk; it is up to the woman to decide

the degree of risk she is willing to take since she is under no obligation to

take any at all. Our recommendation is to make a judicious assessment of the

existence of risk without limiting the certification thereof to the presence of

any illness or set degree of risk. This assessment must be comprehensive, i.e.,

it must consider health as a complete physical, mental and social state of well-

being as it is defined by the World Health Organization.

\ The effect on a woman’s mental health does not mean that she loses the

capacity to make decisions about her health and her life. We have often seen

how healthcare service providers confuse “mental health disorder” with

“mental disability.” Mental health disorders, such as depression, anxiety… etc.

do not affect the patient’s ability to make decisions about her life, health or

personal affairs. A distinction must be made between mental health disorder

and diminished autonomy (mental disability). Most mental disorders refer to a

type of emotional or psychological suffering and not to alterations in cognitive

functions.2

\ None of the doctors of Grupo Médico por el derecho a decidir considers

voluntary termination of pregnancy (VTOP) to be the treatment for an illness or

the effects of an unwanted pregnancy, either in the physical or psychological

2 Only when cognitive functions are seriously altered (orientation, memory, attention, language comprehension, abstract thinking, among others) can it be said that there is a “mental disability” or loss of autonomy. An example of this is dementia or very severe mental disorders like schizophrenia that, in certain circumstances, can alter an individual’s autonomy.

19

sense. However, VTOP can alleviate and restore a woman’s well-being and

prevent the pregnancy from becoming a risk to her health.

\ While VTOP does not resolve the conflict of an unwanted pregnancy, it does

allow the resolution of other conflicts: ambivalence regarding one’s life project,

personal commitments, etc. The psychological and emotional development of

a woman –or of any human beings for that matter– is about taking absolute

control of one’s own life. This is part of mental health. In the area of mental

health, a pregnancy termination can be an act of enormous social.

Finally, both the State and the medical community should guarantee the existence of

friendly specialized clinics and services staffed with sensitive personnel and providers

supportive of access to legal abortion services, where women who seek this service are

not subjected to illegal barriers or disproportionate burdens.

20

References1 Logan C., Holcombe E., Manlove J., Ryan S. “The consequences of unintended

childbearing.” The National Campaign to Prevent Teen and Unplanned

Pregnancy. Child Trends, INC, May 2007.

2 Bunevicius R., Kusminskas L., Bunevicius A., Nadisauskiene R.J., Jureniene

K., PopVJ. “Psychosocial risk factors for depression during pregnancy.” Acta

Obstet Gynecol Scand. 2009;88(5):599-605.

3 Najman J.M., Morrison J., Williams G., Andersen M., Keeping J.D. “The mental

health of women 6 months after they give birth to an unwanted baby: a

longitudinal study.” Soc Sci Med. 1991;32(3):241-7.

4 Rich-Edwards J.W., Kleinman K., Abrams A., Harlow B.L., McLaughlin T.J., Joffe

H., Gillman M.W. “Sociodemographic predictors of antenatal and postpartum

depressive symptoms among women in a medical group practice.” J Epidemiol

Community Health. 2006 Mar; 60(3):221-7.

5 Iranfar S., Shakeri J., Ranjbar M., Nazhad Jafar P., Razaie M. “Is unintended

pregnancy a risk factor for depression in Iranian women?” East Mediterr

Health J. 2005 Jul; 11(4):618-24.

6 Eastwood J.G., Phung H., Barnett B. “Postnatal depression and socio-

demographic risk: factors associated with Edinburgh Depression Scale scores

in a metropolitan area of New South Wales, Australia.” Aust N Z J Psychiatry.

2011 Oct 22.

21

7 Laukaran V.H., van den Berg B.J. “The relationship of maternal attitude to

pregnancy outcomes and obstetric complications. A cohort study of unwanted

pregnancy.” Am J Obstet Gynecol. 1980 Feb 1; 136(3):374-9.

8 Lau Y., Keung D.W. “Correlates of depressive symptomatology during the

second trimester of pregnancy among Hong Kong Chinese.” Soc Sci Med.

2007 May; 64(9):1802-11.

9 Barber J.S., Axinn W.G., Thornton A. “Unwanted childbearing, health, and

mother-child relationships.” J Health Soc Behav. 1999 Sep; 40(3):231-57.

10 Schmiege S., Russo N.F. “Depression and unwanted first pregnancy:

longitudinal cohort study.” BMJ. 2005 Dec 3; 331(7528):1303.

11 Hook K. “Refused abortion. A follow-up study of 249 women whose

applications were refused by the National Board of Health in Sweden.” Acta

Psychiatr Scand Suppl. 1963;39(168):1-156.

12 Forssman H., Thuwe I. “One hundred and twenty children born after application

for therapeutic abortion refused. Their mental health, social adjustment and

educational level up to the age of 21.” Acta Psychiatr Scand. 1966;42(1):71-88.

13 Gilchrist A.C., Hannaford P.C., Frank P., Kay C.R. “Termination of pregnancy

and psychiatric morbidity.” Br J Psychiatry. 1995 Aug; 167(2):243-8

14 Ludermir A.B., Araya R, de Araújo T.V., Valongueiro S.A., Lewis G. “Postnatal

depression in women after unsuccessful attempted abortion.” Br J Psychiatry.

2011 Mar; 198(3):237-8.

15 Dagg P.K. “The psychological sequelae of therapeutic abortion—denied and

completed.” Am J Psychiatry. 1991 May; 148(5):578-85.

16 Watter W.W. “Mental health consequences of abortion and refused abortion.”

Can J Psychiatry. 1980 Feb; 25(1):68-73.

17 American Psychological Association, Task Force on Mental Health and

Abortion. (2008). “Report of the Task Force on Mental Health and Abortion.”

Washington, D.C.: Author. Consulted in: http://www.apa.org/pi/wpo/mental-

health-abortion-report.pdf

18 Priscilla K. Coleman. Abortion and mental health: quantitative synthesis and

analysis of research published 1995–2009. BJP September 2011. 199:180-186.

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